core.ac.uk1. modified ida jean orlando’s nursing process theory 9 2. description of age 20 3....

ACKNOWLEDGEMENT

I place my deep sense of admiration to God almighty for his grace, blessing,

guidance and support which strengthened me in the research process and sustained me

throughout this endeavor.

First and foremost I offer my sincere gratitude to our Chairman Dr. Nalla G.

Palaniswami, M.D.,AB (USA), Chairman And Managing Director, Kovai Medical

Center And Hospital and our respected Trustee Dr. Thavamani D. Palaniswami

M.D.,AB (USA), Managing Trustee, Kovai Medical Center And Hospital for giving me

an opportunity to undertake my Post Graduation programme in this esteemed institution.

I grab this occasion to express my deep sense of gratitude to Prof. DR. S.

Madhavi, M.Sc. (N), Ph.D, Principal, KMCH College of Nursing, who was my

Research guide who had supported throughout my study with her valuable knowledge in

research and in statistics.

I am grateful to Dr. N.Selvarajan M.D., Head, Department of Anesthesiology,

for his conscientious approach, guidance and encouragement to complete this thesis

successfully.

It is my distinct honor and privilege to have worked under the able guidance,

continuous supervision and constant encouragement of A. Saratha M.Sc (N) Associate

professor, in the department of medical surgical nursing. I really consider myself very

fortunate to get the benefit of her vast experience and valuable guidance.

I convey my deep sense of gratitude to Prof. (Mrs.) Sivagami .R. M, M.Sc. (N),

Vice Principal, KMCH College of Nursing as well as our joyous Coordinator of II year

M.Sc (N) students for her generous support, encouragement and timely advice to fulfill

this work.

I whole heartedly extend my gratitude to Dr. D. Dhanapal, Dr. Subbiah

Chelliah., Dr. D.Arunkumar, Dr. Arun Prasath, Dr. Harendra Singh, Dr. Vinoth

Kumar and Dr. Vivekanandhan Department of Anesthesiology, for their sustained

patience, keen support, dedication and interest in the accomplishment of this task.

My humble thanks to Prof. Mr. P. Kuzhanthaivel, M. Sc (N)., who whole

heartedly involved in the topic and his comments and constructive criticism at different

stages of my study were thought provoking.

Words are inadequate in offering my thanks, to Prof.Mr.Balasubramaniam

M.Sc.(N), Prof. Mrs. Viji, M.Sc(N), Ph.D, V.C. Jayalakshmi, M.Sc (N) & Ms. Sathya,

M.Sc (N), Assistant Professors, Ms. Priyadharshini, M.Sc (N), & Ms. Renuka, M.Sc

(N), Lecturers, Department of Medical Surgical Nursing who had helped me to refine

my study by their thought provoking ideas.

My deepest gratitude to all the faculty of KMCH College of Nursing for their

contribution and never ending support throughout the study process.

I would like to thank Mrs. Christy Anbu Hepziba., Nursing Supervisor, Mrs.

Manimozhi., OT Technician in charge and my special thanks to all Post Anaesthesia

Care Unit staff nurses, OT Technicians of OT complex-II for helping me a lot in the

throughout my study.

I am exceedingly thankful to Mrs. J. Vennila. Associate Professor, M.Sc. Bio

Statistician, KMCH College of Pharmacy, for her guidance in statistical analysis and

interpretation of data during the study, Thanks also goes to Mr. Damodharan, MLIS. M.

Phil and Assistant Librarians, KMCH College of Nursing for their help and assistance

in search of references to update the content.

My special thanks to my Classmates and Friends, who directly and indirectly

encouraged and helped me throughout this study.

Above all I am so deeply indebted to My Parents and My Husband for permitting

me to undertake this post graduate program, for their help, motivation, prayer, economic

and moral support and unconditional love and cooperation throughout my study without

that my dream would never have come true.

TABLE OF CONTENTS

CHAPTER CONTENTS PAGE

NO

I INTRODUCTION 1-3

NEED FOR THE STUDY 4

STATEMENT OF THE PROBLEM 6

OBJECTIVES OF THE STUDY 6

OPERATIONAL DEFINITIONS 6

HYPOTHESIS 7

ASSUMPTIONS 7

CONCEPTUAL FRAMEWORK 7

II REVIEW OF LITERATURE 10

III METHODOLOGY 14-17

RESEARCH DESIGN 14

VARIABLES UNDER THE STUDY 14

SETTING OF THE STUDY 14

POPULATION OF THE STUDY 15

SAMPLE 15

SAMPLE SIZE 15

SAMPLING TECHNIQUE 15

CRITERIA FOR SAMPLE SELECTION 15

DESCRIPTION OF THE TOOL 16

VALIDITY AND RELIABILITY OF THE

TOOL

16

PILOT STUDY 16

PROCEDURE FOR DATA COLLECTION 16

ETHICAL CONSIDERATION 17

STATISITICAL ANALYSIS 17

IV DATA ANALYSIS AND

INTERPRETATION

18-51

V DISCUSSION, SUMMARY,

CONCLUSION, IMPLICATIONS,

LIMITATIONS AND

RECOMMENDATIONS

52-58

VI ABSTRACT 59

VII REFERENCES 60-64

VIII APPENDICES

LIST OF TABLES

TABLE TITLE PAGE.NO

1. Schematic representation of the data analysis plan 17

2. Description of demographic variables 19

3. Description of clinical characteristics 25

4. Distribution of subjects according to demographic

variables

35

5. Distribution of subjects according to clinical

characteristics

36

6. Repeated measures ANOVA of oxygenation at

various time periods in PACU.

37

7. Repeated measures ANOVA of trends score of

pattern of respiration at various time periods in

PACU.

38

8. Repeated measures ANOVA of heart rate at


39

9. Repeated measures ANOVA of blood pressure at


40

10. Repeated measures ANOVA of consciousness at


41

11. Repeated measures ANOVA of pain score at


42

12. Repeated measures ANOVA of temperature at


43

13. Repeated measures ANOVA of urine output at


44

14. Repeated measures ANOVA of skin color at


45

15. Repeated measures ANOVA of presence of

protective reflex at various time periods in PACU.

46

16. Repeated measures ANOVA of activity at various

time periods in PACU.

47

17. Repeated measures ANOVA of wound drainage

color at various time periods in PACU.

48

18. Repeated measures ANOVA of wound drainage

amount at various time periods in PACU.

49

19. Repeated measures ANOVA of surgical bleeding

at various time periods in PACU.

50

20. Repeated measures ANOVA of nausea and

vomiting at various time periods in PACU.

51

LIST OF FIGURES

FIGURE

NO

FIGURES PAGE.NO

1. Modified Ida Jean Orlando’s Nursing Process Theory 9

2. Description of Age 20

3. Description of Gender 21

4. Description of Marital status 21

5. Description of Education 22

6. Description of Occupation 22

7. Description of Previous operation 23

8. Description of Presence of chronic diseases 23

9. Description of Type of anesthesia 24

10. Description of Oxygenation 27

11. Description of Pattern of respiration 28

12. Description of Heart rate 28

13. Description of Blood pressure 29

14. Description of Consciousness 29

15. Description of Pain score 30

16. Description of Temperature 30

17. Description of Urine output 31

18. Description of Skin color 31

19. Description of Presence of protective reflex 32

20. Description of Activity 32

21. Description of Wound drainage color 33

22. Description of Wound drainage amount 33

23. Description of Surgical bleeding 34

24. Description of Nausea and vomiting 34

25. Mean score of oxygenation measurement at various

time periods in PACU

37

26. Mean score of pattern of respiration measurement at

various time periods in PACU

38

27. Mean score of heart rate measurement at various time

periods in PACU

39

28. Mean score of blood pressure measurement at various


40

29. Mean score of consciousness measurement at various


41

30. Mean score of pain score measurement at various time

periods in PACU

42

31. Mean score of temperature measurement at various time

periods in PACU

43

32. Mean score of urine output measurement at various time

periods in PACU

44

33. Mean score of skin color measurement at various time

periods in PACU

45

34. Mean score of presence of protective reflex

measurement at various time periods in PACU

46

35. Mean score of activity measurement at various time

periods in PACU

47

36. Mean score of wound drainage color measurement at


48

37. Mean score of wound drainage amount measurement at


49

38. Mean score of surgical bleeding measurement at various


50

39. Mean score of nausea and vomiting measurement at


51

LIST OF APPENDICES

APPENDIX TITLE

A. Demographic variables

B. Clinical characteristics (modified early warning

scoring system)

C. Institutional ethics committee approval

D. Letter of Expert’s guidance

E. Certification of tool validity

F. Certification of content validity

G. List of Experts

LIST OF ABBREVIATIONS

S.NO ABBREVIATION ACRONYMS

1. Early warning scoring system EWSS

2. Modified early warning scoring system MEWS

3. Post Anaesthetic recovery scoring system PAS

4. Post Anaesthesia care unit PACU

5. National Patient Safety Agency NPSA

6. National institute for clinical excellence NICE

7. Operation theatre OT

8. Standard deviation SD

9. Analysis of variance ANOVA

10. Repeated measure analysis of variance RM ANOVA

11. Social statistical package for the social science SPSS

12. American Society Post Anaesthesia Nurses ASPAN

1

CHAPTER - I

INTRODUCTION:

The period in the post-anaesthesia care unit (PACU) is critical for the patients.

The aims of the nursing care during this period include monitoring patient until stable

status can be achieved, determining the potential problems in addition to the problems

resulted from the anesthetic and surgical intervention, and applying an appropriate

intervention.

All patients who are received general anaesthesia, regional anaesthesia, (or)

monitored anaesthesia care shall meet discharge criteria for modified early warning

scoring system. The physiological criteria that must be met for the safe discharge from

post-anaesthesia care. Discharge criteria inclusive of a post anaesthesia recovery score

system (PAS), will be used by the anaesthesia care RN to assess patient’s readiness for

discharge from post anaesthesia care.

(The Joint Commission Accreditation Manual for Hospitals)

These mainly focus on providing post anaesthesia patient care to the patient in

the immediate post anaesthesia period, post anesthetic assessment guidelines are often

focused on the role of the anesthesiologist however, due to nurses central role in the

management of patients in the PACU setting, anesthesiologists often delegate the

responsibility for evaluation of patient suitability for discharge to the PACU nurse.

The basic nursing practice of evidence is fundamental to optimal and effective

care. Physiological parameters are used to assess a patient for discharge from a PACU.

In 1970 Aldrete was the first to propose a scoring method to evaluate patient

readiness for discharge from the immediate post -operative recovery area. Aldrete

asserted that a method for evaluation should be simple to implement, too easy to

memories, have a low burden on PACU staff and be applicable to patients in all post -

operative situations. (Dr. Nicole M. Phillips DipAppSc (Nsg)).

The time immediately following a general anaesthetic is a critical period for

patient recovery. Requiring intensive observation to enable early detection of

2

complications from surgery. Since its introduction 1923, the post anaesthesia care unit

(PACU) has been the preferred location for the immediate recovery of the post -

operative patient.

The patient’s length of stay in the PACU is dependent upon a number of factors,

including pre- operative health status, surgical procedure, type of anaesthetic and the

stability of vital signs, it has been common practice for PACU discharge policies to

stimulate a minimum length of stay, with a patient’s readiness for discharge

traditionally relying upon nursing assessment of normality and stability of

physiological parameters.

The Early Warning Scoring System, or EWSS, which can encourage early

intervention, timely transfer to a higher level of care and prevention of codes. EWSS

originated in the United Kingdom. Over the last few years, U.S. hospitals have begun

to utilize the tool here in the states. Implementing EWSS “adds another layer of early

detection to the RRT system” and allows the healthcare team to intervene earlier. One

widely used version is the Modified Early Warning System (MEWS). Healthcare

personnel enter vital signs on a chart form that has red-shaded zones to identify findings

outside the normal range for six vital signs, namely: Respiratory rate, heart rate, blood

pressure, level of consciousness, temperature and hourly urinary output.( By Bette

Case DI Leonardi).

The recovering patient is awake, opens eyes, extubated, blood pressure and

pulse are satisfactory, can lift head on command, not hypoxic, breathing quietly and

comfortably, appropriate analgesic, has been prescribed and is safely established fit for

the ward.

Now days, hospitals are treating increasingly complex patients with multiple

co-morbidities. At any given time some of these patients may be rapidly deteriorating,

for a variety of reasons. Every hospital must have a strategy to identify such patients,

and be capable of providing the appropriate level of care at the right time. Early

intervention on a patient who is deteriorating is likely to improve that patient outcome.

3

The intersection of deteriorating patients, early warning scores, a rapid response

team and new monitoring technology well implemented early warning scores can help

rapid response teams in improving outcomes.

The modified early warning scoring system is a simple physiological score that

may allow improvement in the quality and safety of management provided to surgical

ward patients. During the post-operative period, nursing care focuses on reestablishing

the patient’s physiologic equilibrium.

Each individual patient care space is supplied with a cardiac monitor, blood

pressure monitoring device, pulse oximeter, airway management equipment, suction,

and oxygen. Emergency medications and equipment are centrally located. Isolation

rooms are available if needed.

Nursing care in the immediate postoperative phase focuses on maintaining

ventilation and circulation, monitoring oxygenation, monitoring levels of

consciousness, preventing shock and managing pain.

Morgan, Williams and Wright in the UK in 1997 developed Early Warning

Scores (EWS), a score of five physiological parameters (heart rate, systolic blood

pressure, respiratory rate, temperature and conscious level). Initially, it was not

developed to predict outcome, but to serve as a track-and-trigger system (TTS) to

identify early signs of deterioration. Since it has been modified and in addition to the

original five physiological parameters in most EWS oxygen saturation has been

included.

Modified Early Warning Score or MEWS has been developed to ensure timely

identification of patients at risk of deterioration and prevent delay in intervention or

transfer of critically ill patients.

The MEWS is a tool for nurses to help monitor their patients and improve how

quickly a patient experiencing a sudden decline receives clinical care.

The MEWS is proposed for early identification of patient’s deterioration. The

MEWS calculation can help the anesthetist select the correct level of care to avoid

inappropriate admission to the ICU and to enhance the use of the high dependency unit

after emergency surgical procedures.

4

Modified early warning scores (MEWS) are now commonly used for the

assessment of unwell patients. These simple observations can detect when a patient’s

condition requires a more intense observation and should be a trigger for further

investigation as early intervention can reduce morbidity and mortality in unwell patients

(NPSA 2007)

This tool promotes integration of care, and acts as a method for assessing the

efficacy of medical interventions and can reduce the need for unnecessary hospital

admissions. The MEWS is a tool that is based on physiological parameters and these

should be recorded on an initial assessment for unwell patients (or) as part of routine

monitoring where a patient’s medical condition dictates, heart rate, respiratory rate,

blood pressure, level of consciousness and temperature (NICE 2007).

NEED FOR THE STUDY:

Postoperative complications such as hypoxia, hypotension, hypertension,

changes in consciousness, chronic pain, surgical bleeding, nausea and vomiting,

hypothermia, hyperthermia, skin color changes and changes in dressing site and reflex

abnormalities. So, early identification of complications allows the immediate and

nursing interventions.

In PACU patients early detections of the post-operative complications may

become possible applying the modified early warning scoring system.

The MEWS is providing the systemic approach for patient’s assessment with

risks and help with early identification of patients with worsening clinical status. The

Modified Early Warning Score (MEWS) is a bedside scoring system that is non-

invasive, simple and repeatable to reflect dynamic changes in physiological state a

scoring system using bedside measurements (Early Warning Score, EWS) was

developed in 2001 and initially evaluated in medical admissions and critically unwell

patients. EWS is calculated using hourly measurements of 6 bedside parameters (pulse,

respiratory rate, temperature, conscious level, urine output and blood pressure) to

provide a score of 0-30.

The modified early warning score is a simple, physiological score may allow

improvement in the quality and safety of management provided to surgical ward

5

patients. The primary purpose is to prevent delay in intervention (or) transfer of

critically ill patients.

There has been increasing recognition that the care provided to patients in hospital who

deteriorate clinically, (or) show signs that may deteriorate unexpectedly, has a marked

impact on patient mortality, morbidity and length of stay both in the hospital overall

and in a critical care should they be admitted to critical care.

Clinical deterioration can occur any stage of a patient’s illness, although there

will be certain periods during which a patient is more vulnerable, such as at the onset

of illness, during surgical or medical intervention and during recovery from critical

illness. Patients on general adult wards who are at risk of deteriorating may be identified

before a serious adverse event by changes in physiological observations recorded by

clinical staff.

The interpretation of these changes and timely institution of appropriate clinical

management once physiological deterioration is identified is of crucial importance if

the likelihood of serious adverse events including cardiac arrest and death is to be

minimized. Care strategies following a period of critical illness are also likely to have

a significant impact on patient outcomes.

A recent report from the National Confidential Enquiry into Patient Outcome

and Death (NCEPOD) (An Acute Problem’, NCEPOD 2005) identified delayed

recognition and referral as prime causes of the substandard care of the acutely unwell

patients in hospital. The report found that on a number of occasions this was aggravated

by poor communication between the acute medical, surgical and critical care medical

teams. It also identified examples in which there was a lack of awareness by medical

consultants of their patients deteriorating health and their subsequent admission to

critical care. Admission to an intensive care unit (ICU) was thought to have been

avoidable in 21% of cases and the authors felt that sub-optimal care contributed to about

a third of the deaths that occurred.

This tool aims to assist the registered nurse to determine a course of action in

the event becoming unwell (or) presenting with an abnormal physiological status.

To improve the quality of patient baseline observations and monitoring and

allow for timely intervention (or) if needed admission to hospital.

To improve communication within the multidisciplinary team.

Support clinical judgment and aid in securing appropriate assistance for unwell

patients.

6

MEWS might also be a useful screening tool to triage patients who may require

medical review and intervention.

STATEMENT OF THE PROBLEM:

A study to assess the effectiveness of early warning scoring system and

execution of nursing interventions among patients subjected to open abdominal

surgeries in the Post Anaesthesia Care Unit in KMCH Coimbatore.

1.3 OBJECTIVES:

The objectives of the study are to

Asses the trend of early warning signs of patients following open abdominal

surgeries.

Assess the effectiveness of nursing interventions based on early warning scoring

system among patients following open abdominal surgeries.

To determine the effectiveness of MEWS among patients subjected to open

abdominal surgeries.

1.4 OPERATIONAL DEFINITIONS

EARLY WARNING SCORING SYSTEM (EWSS):

It refers to a guide used by nurses to quickly determine the degree of illness of

a patient. It is based on the six cardinal vital signs. (Respiratory rate, Oxygen saturation,

Temperature, Blood pressure, Pulse/Heart rate, AVPU)

NURSING INTERVENTIONS:

It refers to the actual treatments & actions that are performed to help the patient

to reach the goals that are set for them. The nurse uses his (or) her knowledge,

experience & critical thinking skills to decide which interventions will help the patient

the most.

MAJOR SURGERIES:

It refers to open abdominal procedures extending more than one hour.

7

POST ANAESTHESIA CARE UNIT (PACU):

It is an area, normally attached to operating room suites, designed to provide

care for patients recovering from general anaesthesia, regional anaesthesia or local

anaesthesia.

1.5 HYPOTHESIS:

There will be a significant effect on execution of nursing interventions initiated

based on the early warning scoring system in the prevention of post-operative

complication.

1.6 ASSUMPTION:

The post-operative complication as preventable, if identified early and

intervened appropriately.

The anaesthesia given during surgery induces post-operative complications.

Conceptual framework

The conceptual framework for this study was developed on the basis of Ida

Jean Orlando (Pelletier). She proposed her model in 1926, which was further clarified

and refined in 1961.

Orlando’s Nursing Theory revolves around 5 major interrelated concepts.

1. Function of professional nursing,

2. Presenting behavior of the patient,

3. Immediate (or) internal response of the nurse,

4. Nursing process discipline,

5. Improvement.

1. Nurses responsibility - Refers to the responsibility to see that patients need for

help are met either directly by her own activity (or) indirectly by calling in the

help of others.

8

2. Need-Need is situationally defined as requirement of the patient, which if

supplied relief’s (or) diminishes his\her immediate distress and improve his/her

immediate sense of adequacy (or) well-being.

3. The presenting behavior of the patient - It is any observable, verbal (or) non-

verbal behavior of the patient.

4. Immediate reaction includes nurses and patients' individual perception, thoughts

and feelings.

5. Nursing process discipline includes nurse communicating to patient his/her own

immediate reaction clearly identifying that the item expressed belongs to the

nurse and then asking for validation (or) correction.

6. Improvement means to grow better, to turn, to profit and to use to advantage.

The attributes adopted for this study are

1. Behavior of the patient (Subjective and objective assessment).

2. Reaction of the nurse (Nursing diagnosis, planning for action).

3. Nursing action (Implementing action for the patient’s benefit).

4. Orlando proposes that nurse’s should help relieve physical and mental

discomfort and should not act to the patient distress. This assumption is

evident in the concept of improvement in patient’s behavior as the

indented outcome of the nursing action. This is done in the last phase that

is an evaluation, which helps in a reassessment.

9

CHATPER -II

REVIEW OF LITERATURE:

Nursing Diagnosis Assessment

Assessment of the disturbances in

the health status of the patients

underwent open abdominal surgery

to elicit the physiological problems

that deteriorate the outcome.

Assessment include,

Demographic data, Oxygenation,

respiratory rate, heart rate, blood

pressure, consciousness, pain,

temperature, urine output, skin

color, presence of protective reflex,

activity, wound drainage color,

wound drainage amount, surgical

bleeding, nausea and vomiting.

Diagnosis of actual and potential

nursing problems

Planning

Planning nursing interventions on the

basis of elicited problems in order to

maintain the health status.

Implementation

Implementing priority based nursing

interventions to prevent the

complications

Evaluation

Evaluate the effectiveness of executed

nursing interventions by using same tool

in the assessment phase.

Fig. 1: Modified Ida Jean Orlando’s Nursing Process Theory (1961)

10

CHAPTER – II

REVIEW OF LITERATURE

An extensive review is made to strengthen the present in order to lay down the

foundation. It familiarizes the investigator with a previous investigation related to one

field of interest and various methods and procedure which can be pursued.

The literature reviewed for this study is presented as follows,

MEWS is the timely, early identification of clinical deterioration, prevent the

delayed nursing interventions.

Effect of the modified early warning scoring system in the PACU.

2.1 MEWS is the timely, early identification of clinical deterioration; prevent the

delayed nursing interventions

Petersen JA (2017) EWS reduces complex clinical conditions for a single

number, with the inherent risk to overlook clinical cues and subtle changes in a patient’s

condition. They showed that identifying and treating deteriorating patients is a

collaborative task that requires diverse technical and non-technical skills for staff to

perform optimally.

C.L. Downey (2017) early warning scores provides the right language and

environment for the timely escalation of patient care. They are limited by their

intermittent and user- dependent nature, which can be partially overcome by automation

and new continuous monitoring technologies, although clinical judgment remains

paramount.

Jean Christian (2016) Studied the Applicability of the modified early warning

Score (mews) in predicting outcome of patients Undergoing abdominal surgery and

concluded that The MEWS can be effectively used in patients admitted in surgical

wards in a low resource setting hospitals as an important risk management tool to ensure

timely identification of patients at risk of deterioration and to prevent delay in

Intervention or transfer of critically ill patients.

Wilson et al., (2016) compared clinical acumen of nursing staff in predicting

deterioration and MEWS score and concluded that MEWS score is better.

11

Liljehult, et al (2016) Early warning score is a simple and valid tool for

identifying patients at risk of dying after acute stroke. Readily available physiological

parameters are converted to a single score, which can guide both nurses and physicians

in clinical decision making and resource allocation.

Una kyriacos, (2014) studied A MEWS for developing countries should record

at least seven parameters. Experts from developing countries are best placed to stipulate

cut points in physiological parameters. Further research is needed to explore the ability

of the MEWS chart to identify physiological and clinical deterioration.

Smith ME, et al. (2014) early warning system scores perform well for

prediction of cardiac arrest and death within 48 hours, although the impact on health

outcomes and resource utilization remains uncertain, owning to methodological

limitations. Efforts to assess the performance and effectiveness more rigorously will be

needed as early warning system uses become widespread.

Aravind Suppiah (2014) tells about the Modified Early Warning Score

(MEWS) is a bedside scoring system that is non-invasive, simple and repeatable to

reflect dynamic changes in physiological state. Objective this study aims to assess

accuracy of MEWS and determine an optimal MEWS value in predicting severity in

acute pancreatitis (AP). This is the first report on the novel use of MEWS as a

prognostic indicator in patients referred with Acute Pancreatitis. It is inexpensive,

accessible, and less invasive than any other scoring system used in AP.

Alam N et al. (2014) the EWS it is a simple and easy to use tool at the bedside,

which may be of help in recognizing patients with potential for acute deterioration.

Coupled with an outreach service, it may be used to timely initiate adequate treatment

upon recognition, which may influence the clinical outcomes positively.

Correia N et al. (2014) EWS systems are not widely used in Portuguese health

service clinical worsening, lengths of stay, admission into high care units, and mortality

may be predicted by the EWS.

Naomi e. Hammond, (2012) explains in the MEWS system to identify the

deteriorating patient early so that timely interventions can occur along with improved

patient outcomes .We recommend standardized documentation, continued education,

regular auditing to identify strengths and weakness with the use of the system to assist

nursing staff to accurately record vital signs and be able to recognize deteriorating

patients when using the MEWS system.

12

Churpek MM, et al (2012) the cardiac arrest risk triage score is simpler and

more accurately detected cardiac arrest and intensive care unit transfer than the

modified warning score. Implementation of this tool may decrease rapid response team

resource utilization and provide a better opportunity to improve patient outcomes than

the MEWS.

U. kyriacos (2011) Better monitoring of patients implies better care, but sources

indicate that the impact of vital signs_ monitoring and MEWS/EWS systems has yet to

be tested. Nevertheless, is sufficient evidence of observational work that MEWS/EWS

systems facilitate recognition of abnormal physiological parameters in deteriorating

patients, alerting ward staff to the need for intervention.

Julie Considine in (2009) derangements in temperature, respiratory rate, heart

rate appears to increase risk of critical care admission. Further work using a prospective

approach is needed to establish which physiological parameters have the highest

predictive validity, the level of physiological abnormality with highest clinical utility,

and the optimal timing for collection of physiological data.

V C Burch (2008) the MEWS, specifically five selected parameters, may be

used as a rapid, simple triage method to identify a medical patient’s in need of hospital

admission and those at increased risk of in hospital death.

Thorpe et al., in (2006) studies the use of NEWS in 334 surgical in patients and

concluded that the MEWS in association with a call-out algorithm is a useful and

appropriate risk-management tool that should be implemented for all surgical

inpatients.

J Gardner -Thorpe. In (2006) The MEWS in association with a call-out

algorithm is a useful and appropriate risk management tool that should be implemented

for all surgical patients.

2.2 Effect of the modified early warning scoring system in the PACU.

Blankush JM, in (2017) studied the MEWS with etco2 for postoperative

monitoring and concluded that the combination of MEWS and etco2 is a reliable

indicator combination of MEWS and etco2 is a reliable indicator of post-operative

morbidity.

Erlend Skraastad (2017) studied the ESS fulfills suggested criteria for score

quality validation and reflects the patients post-operative status adequately and with

high sensitivity.

13

Further clinical trials are warranted to evaluate the usefulness of ESS as a simple tool

for assessment of the post-operative safety and quality of patients.

Hollis RH et al (2016) studied the critical post- operative complications can

be preceded by rising EWS. Intervention studies are needed to evaluate whether EWS

can reduce the severity of post -operative complications and mortality for surgical

patients through early identification and intervention.

Laura P.Dowling fall (2015) studied, it is anticipated that a new Aldrete

discharge scoring tool will be instituted as the discharge protocol for phase1PACU.

Using a standardized tool provides consistency of care, reduces errors, promotes

efficient use of resources, meets joint commission requirements, and meets ASPAN

recommended standards. The use of the scoring tool should be taught as part of

orientation to the unit.

Berrin Pazar, ayla yava (2013) The use of the EWSS and nursing guide, when

physiological parameters are monitored by patients during their PACU stay had positive

effects on outcomes and provided early recognition and treatment of the post -operative

complications. The use of the EWSS and nursing guide are suggested to be also

continued after the patient was transferred toward from PACU and the follow-up should

be maintained in this manner up to at least 24 hours after the operation.

Peris A (2012) studied the purpose of MEWS in emergency abdominal surgery

post- operative and concluded that the use of a simple and reproducible score system

may help in reducing ICU admissions after emergency surgery.

Dr.Nicole M. Phillips DipAppSc (Nsg), -2011 studied there was general

agreement amongst the studies that post-anesthetic Care unit discharge assessment

should consider levels of pain, conscious state, and nausea and vomiting. Although vital

signs were included in all the discharge assessment tools, there was variation in the

specific vital signs included within tools, with blood pressure being the only vital sign

consistently used. The value of including urine output, oral intake or psychomotor

testing in assessing readiness for post-anesthetic care unit. Discharge was inconclusive

and therefore requires further investigation.

Kyriacos et al., (2009) studied MEWS for postoperative monitoring and

concluded that MEWS provides a reliable picture of clinical deterioration and

appropriate intervention.

14

CHAPTER - III

METHODOLOGY:

The study was designed to determine the effectiveness of early warning scoring

system for execution of nursing interventions among patients subjected to open

abdominal surgeries in the PACU at KMCH, Coimbatore. This chapter deals with the

methods adopted by the researcher such as research design, variables, setting of the

study, population, sample, sample size, sample technique, criteria for sample selection,

description of the tool, validity and reliability of the tool, pilot study, procedure for data

collection, ethical consideration and statistical analysis.

RESEARCH DESIGN:

The research design adopted for the study was single group pretest posttest

design.

VARIABLES UNDER THE STUDY:

a) Independent variable:

The independent variable in this study was modified early warning scoring

system based on interventions.

b) Dependent variable:

The dependent variables in this study are post-operative complications.

SETTING OF THE STUDY:

This study was conducted in Kovai Medical Center Hospital, Operation

Theater-II in PACU Coimbatore. It is a multi-specialty hospital with NABH

accreditation, consisting of 800 beds with modern facilities and excellence in the health

care delivery system. In Operation Theater - II monthly 20 numbers of open abdominal

surgeries are performed. The patients will be kept for observation for 3-4 hours in the

PACU.

During the observation in PACU the patients are having a high risk of

developing many complications. Early & Prompt identification will save the life of the

15

patient. When the patient is hemodynamically stable, the patient will be shifted to post-

operative surgical ward.

POPULATION OF THE STUDY:

The target population were patients in the age group of above 20years subjected

to open abdominal surgery. The accessible population were patients posted for open

abdominal surgery in Kovai Medical Center and Hospital, South India.

SAMPLE:

Patients admitted to KMCH for surgery, who met the inclusion criteria during

the period of the study.

SAMPLE SIZE:

The sample size for the study was 25 patients.

SAMPLING TECHNIQUE:

Non probability purposive sampling technique was adopted for sample

selection. Those who fulfilled the selection criteria and willing to participate were

recruited for the study.

CRITERIA FOR SAMPLE SELECTION:

a) Inclusion Criteria:

Patients who are

Aged above 20 of both male & females.

The patients who underwent major open abdominal surgeries.

b) Exclusion Criteria:

The patients who were critically ill.

Re- exploration of open abdominal surgery.

16

DISCRIPTION OF THE TOOL:

Extensive review of literature, discussion and views of experts enhanced the

development of the tool. They consisted of 4 sections.

Part I: Demographic variables such as age, sex, education, occupation, previous

operations, presence of chronic diseases, type of anaesthesia.

Part II: Clinical variables such as oxygenation, heart rate, respiratory rate, blood

pressure, skin color, urine output, protective reflex, wound drainage color, wound

drainage amount, surgical bleeding, nausea and vomiting.

Part III: To determine the effectiveness of MEWS among patients subjected to open


VALIDITY AND RELIABILITY OF THE TOOL;

All the contents were reviewed for face and content validity by medical and

nursing experts and they were pilot tested to assess the usability and early detection and

prevention of post -operative complications.

Content validity of the tool was established by experts comprising of experts

from the field of nursing, anesthetics and surgeon. The researcher gave a copy of the

tool and explained the purpose and objective of the study to them individually. The

panel of content experts were asked to rate the tool that early detection and prevention

of post - operative complications on implementation of modified early warning scoring

system.

PILOT STUDY;

The pilot study was conducted in operation theatre-II of KMCH, Coimbatore.To

ascertain the feasibility of the study. Formal permission was obtained before pilot study.

Pilot study has been conducted with 7 patients in the study group. The collected data

were analyzed. The analysis of the pilot study revealed that it was feasible and

practicable to conduct the main study. The reliability of the tool was also established in

the pilot study. And the same was approved and the investigator was permitted to

proceed with the main study.

PROCEDURE FOR DATA COLLECTION;

On the first day of the holding area, while subjects were comfortable (or) when

the physician and nurse completed the routine procedure, patients who met the inclusion

criteria were approached consecutively by the researcher and were explained the

purposes and procedures in detail.

17

The patients were assured that they were free to withdraw during the study

without any compromise in subsequent treatment.

This study, if the patient’s MEWS score was >15, a 10 minute follow-up are

performed. If the MEWS score was

18

CHAPTER - IV

DATA ANALYSIS AND INTERPRETATION

This chapter deals with the analysis and interpretation of data collected from the

subjects to assess the early warning scoring system and post-operative complications

from the post anaesthesia care unit. The findings are as follows:

SECTION A : Description of demographic variables

SECTION B : Description of clinical Characteristics

SECTION C : Distribution of subjects according to demographic variables

SECTION D : Distribution of subjects according to clinical characteristics

SECTION E : Determine the effectiveness of MEWS among patients subjected to

open abdominal surgeries.

19

SECTION – A

Table 2. DESCRIPTION OF DEMOGRAPHIC VARIABLES

S.No Demographic Variables Frequency (f) Percent (%)

1 Age in years

20-40 years 6 24

41-60 years 15 60

61-80 years 4 16

2 Gender

Male 13 52

Female 12 48

3 Marital Status

Unmarried 3 12

Married 22 88

4 Education

Primary 1 4

Secondary 8 32

Degree 16 64

5 Occupation

Agriculture 3 12

Coolie 4 16

Profession 11 44

Home maker 7 28

6 Previous Operation

Yes 21 84

No 4 16

7 Presence of Chronic Diseases

DM/HT 8 32

Others 5 20

None 12 48

8 Type of Anaesthesia

GA 21 84

RA 4 16

Table 2 presents the frequency and percentage distribution of demographic

variables among patients in the PACU. 6 (24%) of them were in the age group of 20 -

40 years, 15 (60%) belongs to 41 - 60 years of age group, 4 (16%) were between 61-80

years of age group. 13 (52%) were male, 12 (48%) were female. 3 (12%) were

unmarried, 22 (88%) were married, 1 (4%) of the subjects had primary education, 8

20

(32%) were having secondary education, 16 (64%) were having degree education.

Based on occupation 3 (12%) were agriculture, 4 (14 %) were coolie, 11 (44 %) were

professional, 7 (28 %) where home maker. 21 (84%) had previous operation, 4 (16%)

had no previous operation. 8 (32%) had presence of chronic disease like DM/HT, 5

(20%) had other chronic disease, 12 (48%) did not have any chronic disease. 21 (86%)

were undergoing surgery under GA, 4 (16%) had RA .

All above table describe the distribution of demographic variables of the subjects.

Figure 2: Distribution of subjects based on Age

0

2

4

6

8

10

12

14

16

20-40 41-60 61-80

Age

20-40

41-60

61-80

21

Figure 3: Distribution of subjects based on Gender

Figure 4: Distribution of subjects based on Marital Status

0

5

10

15

20

25

Unmarried Married

Marital Status

Unmarried

Married

11

12

12

12

12

12

13

13

13

male female

Gender

male

female

22

Figure 5: Distribution of subjects based on Education

Figure 6: Distribution of subjects based on Occupation

0

2

4

6

8

10

12

14

16

Primary Secondary Degree

Education

Primary

Secondary

Degree

0

2

4

6

8

10

12

Agri Coolie Profession Home maker

Occupation

Agri

Coolie

Profession

Home maker

23

Figure 7: Distribution of subjects based on Previous Operations

Figure 8: Distribution of subjects based on Presence of Chronic Disease

Previous Operation

Yes

No

Presence of Chronic Disease

DM/HT

Others

None

24

Figure 9: Distribution of subjects based on Type of Anaesthesia

Type of Anaesthesia

GA

RA

25

SECTION – B

Table 3. DISTRIBUTION OF CLINICAL VARIABLES

S.NO CLINICAL

PARAMETER MEWS SCHEDULE

FREQUENCY

(F)

PERCENT

(%)

1 Oxygenation 1 SPO2>90%

on Oxygen 24 96

2 SPO2>92%

on room air 1 4

2 Pattern of

Respiration 1

Dyspnea or

Shallow

breathing

11 44

2

Can deep

breathe &

Cough well

14 56

3 Heart Rate 0 111-129 b/m 1 4

1 101-110 b/m 14 56

2 50-100 b/m 10 40

4 Blood Pressure 1

BP +/-20-

50mmHg of

pre-op level

12 48

2

BP +/-

20mmHg of

pre-op level

13 52

5 Consciousness 1 Arousable on

Calling 12 48

2 Fully awake 13 52

6 Pain Score 1 Moderate (4-

6) 20 80

2 Minimal (0-

3) 5 20

7 Temperature 1 98.6°F -

99.5°F 9 36

2 95.0°F -

98.6°F 16 64

8 Urine Output 1 20 - 30

ml/HR 15 60

2 >30 ml/HR 10 40

26

9 Skin color 1

Pale, "dusky"

or "blotchy",

discoloration,

as well as

jaundice

4 16

2 Pink 21 84

10 Presence of Protective

Reflex 1

Diminished

Sluggish 4 16

2 Gag reflex is

Present 21 84

11 Activity 0

Not able to

move any

extremity

1 4

2 Able to move

4 extremities 24 96

12 Wound Drainage Color 1 Sanguineous 10 40

2 Serous 15 60

13 Wound Drainage Amount 1 Moderate 18 72

2 Minimal 7 28

14 Surgical Bleeding 1 Moderate 1 4

2 None (or)

Minimal 21 96

15 Nausea and Vomiting 1

Moderate and

treated with

IV

medications

24 96

2 None 1 4

Table 3 presents the frequency and percentage distribution of clinical variables

among patients in the PACU. 24 (96%) was spo2 >90% of oxygen, 1 (4%) was spo2

>92% on room air. 11 (44%) had dyspnea and shallow breathing, 14 (56%) can deep

breathe and cough well. 1 (4%) had a heart rate between 111-129 b/m, 14 (56%) had a

heart rate between 101-110 b/m, 10 (40%) had a heart rate between 50-100 b/m. 12

(48%) had BP +/- 20-50mmHg of pre-operative level, 13 (52%) had BP +/- 20 mm Hg

of pre-operative level. 12 (48%) were arousable on calling, 13 (52%) were fully awake.

20 (80%) had moderate pain (4-6), 5 (20%) had minimal pain (0-3). 9 (36%) had a

temperature between 98.6F- 99.5F, 26 (64%) had a temperature between 95.0F- 98.6F.

15 (60%) had a urine output of 20-30 ml/HR, 10 (40%) had urine output of more than

30 ml/HR. 4 (16%) of subjects was skin color is pale, as well as present with jaundice,

21 (84%) of subject's skin color was normal pink. 4 (16%) of subjects reflex is

27

diminished/ sluggish, 21 (84%)of subjects gag reflex was normal. 1 (4%) had not able

to move any extremity, 24 (96%) were able to move 4 extremities. 10 (40%) had

sanguineous wound drainage, 15 (60%) had serous wound drainage. 18 (72%) had

moderate wound drainage amount 7 (28%) had minimal wound drainage amount. 15

(60%) had moderate surgical bleeding, 10 (40)% had none (or) minimal surgical

bleeding. 24 (86%) had moderate nausea and vomiting treated with IV medications, 1

(4%) had no vomiting.

All above table describe the distribution of Clinical variables of the subjects.

Figure 10: Distribution of subjects based on Oxygenation

0

5

10

15

20

25

1(spo2>90% on oxygen) 2(spo2>92% on roomair)

Oxygenation

1(spo2>90% on oxygen)

2(spo2>92% on room air)

28

Figure 11: Distribution of subjects based on Respiratory Rate

Figure 12: Distribution of subjects based on Heart Rate

0

2

4

6

8

10

12

14

16

1(dyspnea) 2(deep breathe)

Respiratory Rate

1(dyspnea)

2(deep breathe)

0

2

4

6

8

10

12

14

0(50-100 b/m) 1(101-110 b/m) 2((111-129 b/m)

Heart Rate

0(50-100 b/m)

1(101-110 b/m)

2((111-129 b/m)

29

Figure 13: Distribution of subjects based on Blood Pressure

Figure 14: Distribution of subjects based on Consciousnes

11

12

12

12

12

12

13

13

13

13

1(+/- 20-50 mmHg) 2(+/- 20mmHg)

Blood Pressure

1(+/- 20-50 mmHg)

2(+/- 20mmHg)

Consciousness

1(arousable on calling )

2(fully awake)

30

Figure 15: Distribution of subjects based on Pain

Figure 16: Distribution of subjects based on Temperature

0

2

4

6

8

10

12

14

16

18

20

1(moderate 4-6) 2(Normal 0-3)

Pain

1(moderate 4-6)

2(Normal 0-3)

0

2

4

6

8

10

12

14

16

1(98.6-99.5F) 2(95.0-98.6F)

Temperature

1(98.6-99.5F)

2(95.0-98.6F)

31

Figure 17: Distribution of subjects based on Urine Output

Figure 18: Distribution of subjects based on Skin Color

0

2

4

6

8

10

12

14

16

1(20-30 ml/hr) 2(>30 ml/hr)

Urine Output

1(20-30 ml/hr)

2(>30 ml/hr)

0

5

10

15

20

25

1(pale,dusky) 2(pink)

Skin Color

1(pale,dusky)

2(pink)

32

Figure 18: Distribution of subjects based on Presence of Protective Reflex

Figure 19: Distribution of subjects based on Activity

0

5

10

15

20

25

1(diminished) 2(gag reflex present)

Reflexes

1(diminished)

2(gag reflex present)

0

5

10

15

20

25

30

0(able to move 2extremities)

2(able to move 4extremities)

Activity

0(able to move 2 extremities)

2(able to move 4 extremities)

33

Figure 20: Distribution of subjects based on Wound Drainage Color

Figure 21: Distribution of subjects based on Wound Drainage Amount

0

2

4

6

8

10

12

14

16

1(sanguineous) 2(serous)

Wound Drainage Color

1(sanguineous)

2(serous)

0

2

4

6

8

10

12

14

16

18

1(moderate) 2(minimal)

Wound Drainage Amount

1(moderate)

2(minimal)

34

Figure 22: Distribution of subjects based on Surgical Bleeding

Figure 23: Distribution of subjects based on Nausea and Vomiting

0

2

4

6

8

10

12

14

16

1(Moderate) 2(none/ minimal)

Surgical Bleeding

1(Moderate)

2(none/ minimal)

0

5

10

15

20

25

1(moderate treat IVmedication

2(none/minimalcontrolled PO

medication

Nausea & Vomiting

1(moderate treat IV medication

2(none/minimal controlled POmedication

35

SECTION – C

DISTRIBUTION OF SUBJECTS ACCORDING TO DEMOGRAPHIC

CHARACTERISTICS

VARIABLES MEAN STANDARD DEVIATION

Age 1.92 0.64031

Gender 1.48 0.5099

Marital Status 1.88 0.33166

Education 3.6 0.57735

Occupation 2.88 0.97125

Previous Operations 1.16 0.37417

Presence of Chronic Diseases 2.16 0.89815

Type of Anaesthesia 1.16 0.37417

Table 4 distribution of subjects according to demographic characteristics the

Age (mean=1.92 SD=0.64, Gender (mean=1.48, SD= 0.50), Marital status (mean= 1.88

SD-0.33), Education (mean=3.6 SD=0.57), Occupation (mean= 2.88, SD= 0.97),

Previous operations (mean=1.16 SD=0.37), Presence of chronic diseases (mean= 2.16

SD= 0.89), Type of anaesthesia (mean=1.16 SD=0.37).

36

SECTION - D:

DISTRIBUTION OF SUBJECTS ACCORDING TO CLINICAL VARIABLES

VARIABLES MEAN STANDARD DEVIATION

Oxygen 1.04 0.200

RR 1.56 0.506

HR 1.36 0.568

BP 1.52 0.509

Consciousness 1.52 0.509

Pain 1.20 0.408

Temperature 1.64 0.489

Urine Output 1.40 0.500

Skin Color 1.84 0.374

Protective Reflex 1.84 0.374

Activity 1.92 0.400

Wound Drainage Color 1.60 0.500

Wound Drainage Amount 1.28 0.458

Surgical Bleeding 1.40 0.500

Nausea and Vomiting 1.04 0.200

Table 5 shows the distribution of subjects based on clinical characteristics such

as Oxygen (mean=1.04 SD=0.20), Respiratory rate (mean=1.56 SD=0.50), Heart rate

(mean=1.36 SD=0.56), Blood pressure (mean= 1.52 SD=0.50), Consciousness

(mean=1.52 SD=0.50), Pain (mean=1.20 SD=0.40), Temperature (mean=1.64

SD=0.48), Urine output (mean=1.40 SD=0.50), Skin color (mean=1.84 SD=0.37),

Protective reflex (mean=1.84 SD=0.37), Activity (mean=1.92 SD=0.4), Wound

drainage color (mean=1.60 SD=0.5), Wound drainage amount (mean=1.28 SD=0.45),

Surgical Bleeding (mean=1.4 SD=0.5), Nausea and Vomiting (mean=1.04 SD=0.2).

37

SECTION - E

Determine the effectiveness of MEWS among patients subjected to open


Table 6 repeated measures ANOVA of oxygenation at various time periods in

the PACU.

N=25

Time (Periods) Mean Std. Deviation F Value

Ox1 (arrival time) 1.12 .43970 27.56*

Ox 2 (30 mins) 1.16 .37417

Ox 3 (1 hr) 1.6 .50000

Ox 4 (1 1/2 hrs) 1.96 .20000

Ox 5 (2 hrs) 2 0.00000

Figure 24 depicts the changes in oxygenation of the participants. It could be noted that

by 2 hours Post anaesthetic the oxygenation was good.

1.12

1.16

1.6

1.96 2

0

0.5

1

1.5

2

2.5

(arrival time) (30 mins) (1 hr) (1 1/2 hrs) (2 hrs)

Axi

s Ti

tle

Oxygenation

38

Table 7 Repeated measure ANOVA Trend scores of pattern of respiration at

various time periods in the PACU.

N=25

Figure 25 depicts the changes in trend scores of a pattern of respiration of the

participants. It could be noted that by 30 minutes and 2 hours Post anaesthesia the

pattern of respiration was good.

1.96

2.0

1.961.96

2.0

1.94

1.95

1.96

1.97

1.98

1.99

2

2.01


Respiration


RR1(arrival time) 1.96 .20000

1.0*

RR 2 (30 mins) 2 0.00000

RR 3 (1 hr) 1.96 .20000

RR 4 (1 1/2 hrs) 1.96 .20000

RR 5 (2 hrs) 2 0.00000

39

Table 8 Repeated measure ANOVA of heart rate at various time periods in the PACU.

N=25

Figure 26 depicts the changes in heart rate in the participants. It could be noted that by

2 hours Post anaesthetic the heart rate was good

1.68 1.641.72

1.88 2.00

0

0.5

1

1.5

2

2.5


Heart rate


HR 1 (arrival time) 1.68 .55678

2.28*

HR 2 (30 mins) 1.64 .56862

HR 3 (1 hr) 1.72 .54160

HR 4 (1 1/2 hrs) 1.88 .33166

HR 5 (2 hrs) 2.00 0.00000

40

Table 9 Repeated measures ANOVA of blood pressure at various time periods in

PACU.

N=25


Bp1 (arrival time) 1.64 0.4899

3.53* Bp2 (30mins) 1.64 0.4899

Bp3 (1 hr) 1.68 0.4761

Bp4 (1 1/2 hrs) 1.88 0.33166

Bp5 (2 hrs) 2 0

Figure 27 depicts the changes in blood pressure in the participants. It could be noted

that by 2 hours Post anaesthetic the blood pressure was good.

1.64 1.64 1.681.88

2.00

0

0.5

1

1.5

2

2.5

(arrival time) 30 mts 1 hr 1 1/2 hrs 2 hrs

Blood pressure

41

Table 10 Repeated measure ANOVA of consciousness at various time periods in the

PACU.

N=25

Time (Periods) Mean Std.

Deviation F Value

Cs1 (arrival time) 1.6 0.5

4.88*

Cs 2(30 mins) 1.64 0.4899

Cs 3 (1 hr) 1.88 0.33166

Cs 4(1 1/2 hrs) 2 0

Cs 5(2 hrs) 2 0

Figure 28 depicts the changes in consciousness of the participants. It could be noted

that by 1½ hours and 2 hours, post anaesthetic the consciousness was good.

1.6 1.64

1.882.00 2.00

0

0.5

1

1.5

2

2.5

arrival time 30 mins 1 hr 1 1/2 hrs 2 hrs

Axi

s Ti

tle

Consciousness

42

Table 11 Repeated measure ANOVA of pain at various time periods in the PACU.

Time (Periods) Mean Std. Deviation F value

P1(arrival time) 1.6 0.5

11.14*

P2 (30 mts) 1.6 0.5

P3 (1 hr) 1.48 0.5099

P4 (1 1/2 hr) 1.72 0.45826

P5 (2 hrs) 2 0

Figure 29 depicts the changes in pain of the participants. It could be noted that by 2

hours, post anaesthetic the pain score was good.

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

arrivaltime

30 mts 1 hr1 1/2 hr

2 hrs

1.61.6

1.48

1.72

2.00

Pain

arrival time

30 mts

1 hr

1 1/2 hr

2 hrs

43

Table 12 Repeated measure ANOVA of temperature at various time periods in the

PACU.

N=25

Time (periods) Mean Std. Deviation F value

T1 (Arrival time) 2 0

1.0*

T2 (30 mins) 1.92 0.27689

T3 (1 hr) 1.96 0.2

T4 (1 1/2 hrs) 1.96 0.2

T5 (2 hrs) 2 0

Table 30 depicts the changes in temperature of the participants. It could be noted that

by arrival time and 2 hours, post anaesthetic the temperature was good.

1.88

1.9

1.92

1.94

1.96

1.98

2

arrival time 30 mts 1 hr 1 1/2 hr 2 hr

2

1.92

1.96 1.96

2.00

44

Table 13 Repeated measure ANOVA of urine output at various time periods in the

PACU.

N=25

Time periods Mean Std. Deviation F value

UO 1(arrival time) 1.36

.48990 9.33*

UO 2 (30 mins) 1.44 .50662

UO 3 (1 hr) 1.80 .40825

UO 4 (1 1/2 hrs) 1.96 .20000

UO 5 (2 hrs) 2.00 0.00000

Figure 31 depicts the changes in urine output of the participants. It could be noted that

by 2 hours, post anaesthetic the urine output was good.

arrival time 30 mts 1 hr 1 1/2 hrs 2 hrs

1.361.44

1.80

1.96 2.00

Urine output

45

Table 14 Repeated measure ANOVA of skin color at various time periods in the PACU.

N=25


Skin1 (arrival time) 1.36 .48990

1.8*

Skin2 (30 mins) 1.44 .50662

Skin3 (1 hr) 1.80 .40825

Skin4 (1 1/2hrs) 1.96 .20000

Skin5 (2 hrs) 2.00 0.00000

Figure 32 depicts the changes in skin color of the participants. It could be noted that by

2 hours, post anaesthetic skin color was good.

1.36 1.44

1.80

1.962.00

0

0.5

1

1.5

2

2.5


46

Table 15 Repeated measure ANOVA of reflex at various time periods in the PACU.

Figure 33 depicts the changes in protective reflex of the participants. It could be noted

that by arrival time to 2 hours, post anaesthetic the reflex was good.

2.36

2.002.00

1.96 2.00

0.0000

0.5000

1.0000

1.5000

2.0000

2.5000


Reflexes

N=25


reflex1 (arrival time) 2.36 1.80000

reflex2 (30 mins) 2.00 0.00000

reflex3 (1 hr) 2.00 0.00000 1.0*

reflex4 (1 ½ hrs) 1.96 .20000

reflex5 (2 hrs) 2.00 0.00000

47

Table 16 Repeated measure ANOVA of activity at various time periods in the PACU.

N=25

Time periods Mean Std.

Deviation F value

A 1 (arrival time) 1.68 0.74833

2.19*

A 2 (30 mins) 1.68 0.74833

A 3 (1 hr) 1.76 0.59722

A 4 (1 1/2 hrs) 1.92 0.27689

A 5 (2 hrs) 2 0

Figure 34 depicts the changes in the activity of the participants. It could be noted that

by 2 hours, post anaesthetic the activity was good.

1.5

1.55

1.6

1.65

1.7

1.75

1.8

1.85

1.9

1.95

2

arrival time 30 mins 1 hr 1 1/2 hrs 2 hrs

1.681.68

1.76

1.92

2.00

Activity

48

Table 17 Repeated measure ANOVA of wound drainage color at various time periods

in the PACU.

N =25


Color1 (arrival time) 1.96 0.2

1.00* Color2 (30 mins) 1.96 0.2

Color3 (1 hr) 1.96 0.2

Color4 (1 1/2 hrs) 2 0

Color5 (2 hrs) 2 0

Figure 35 depicts the changes in wound drainage color of the participants. It could be

noted that by 1 ½ hours and 2 hours, post anaesthetic wound drainage color was good.

1.96 1.96

1.96

2.00

2.00

1.94

1.95

1.96

1.97

1.98

1.99

2

2.01

arrival time 30 mts 1 hr 1.30 hrs 2 hrs

wound drainage color

49

Table 18 Repeated measure ANOVA of wound drainage amount at various time periods

in the PACU.

N=25


Amount1 (arrival time) 1.44 0.5831

5.68*

Amount2 (30 mins) 1.52 0.58595

Amount3 (1 hr) 1.88 0.33166

Amount4 (1 ½ hrs) 1.96 0.2

Amount5 (2 hrs) 2 0

Figure 36 depicts the changes in the wound drainage amount of the participants. It could

be noted that by 2 hours post anaesthetic the wound drainage amount was good

Wound drainage amount

arrival time

30 mts

1 hr

1 1/2 hrs

2 hrs

50

Table 19 Repeated measure surgical bleeding at various time periods in the PACU.

N=25

figure 38: depicts the changes in surgical dressing of the participants. It could be noted

that by 2 hours post anaesthetic the surgical bleeding was good.

1.7

1.8

1.9

2

arrival time30 mts

1 hr1.30 hrs

2 hrs

1.81.8000

1.96001.9600

2.0000

Surgical bleeding


Bleeding1 (arrival time) 1.8 .50000

Bleeding2 (30 mins) 1.80 .50000

Bleeding3 (1 hr) 1.96 .20000 2.190*

Bleeding4 (1 ½ hrs) 1.96 .20000

Bleeding5 (2 hrs) 2.00 0.00000

51

Table 20 Repeated measure ANOVA of nausea and vomiting at various time periods in

the PACU.

N=25

Figure 39: depicts the changes in nausea and vomiting of the participants. It could be

noted that by 2 hours post anaesthetic Nausea and Vomiting was good.

1.55

1.6

1.65

1.7

1.75

1.8

1.85

1.9

1.95

2

2.05

(arrival time) (30 mins) (1 hr) (1½ hrs) (2 hrs)

Nausea & Vomiting

Time Periods Mean Std. Deviation F value

Nausea 1(arrival time) 1.72 .45826

Nausea 2 (30 mins) 1.72 .45826 6.46*

Nausea 3 (1 hr) 1.92 .27689

Nausea 4 (1½ hrs) 1.92 .27689

Nausea 5 (2 hrs) 2.00 0.00000

52

CHAPTER- V

DISCUSSION, SUMMARY, CONCLUSION, IMPLICATIONS,

LIMITATIONS AND RECOMMENDATION

This chapter deals with discussion, summary and conclusion drawn from the

study. The study limitations, implications and recommendations in different areas of

nursing practice, nursing administration, nursing research and nursing education in the

future are considered here.

The present study is an approach and single group pre-test, post -test design is

used to assess the effectiveness of modified early warning scoring system for execution

of nursing interventions among patients underwent open abdominal surgeries for the

first 2 hours in the PACU. The results of the study, according to the objectives are

discussed as follows,

Demographic variables and modified early warning scoring system

It includes age, gender, marital status, education, occupation, previous

operation, the presence of chronic diseases, type of anaesthesia.

MEWS parameters are oxygenation, respiratory rate, heart rate, blood pressure,

consciousness, pain score, temperature, urine output, skin color, presence of protective

reflex, activity, wound drainage color, amount, surgical bleeding, nausea& vomiting.

The first objective of the study was to assess the trend of early warning signs of

patients following open abdominal surgeries.

Among 25 samples, 24 samples (96%) of them experienced the spo2 > 90% of

oxygen. Remaining 1 sample was experienced by spo2>92% on room air.

Among 25samples, 11 samples (44%) experienced dyspnea (or) shallow

breathing. Remaining 14 samples were experienced that they can deep breathe & cough

well.

Among 25samples, the 1 sample heart rate was 111-129 b/m, 14 samples heart

rate was 101-110 b/m, remaining 10 samples heart rate was 50-100 b/m.

Among 25samples, 12 samples, blood pressure was +/- 20-50 mmHg of pre-op

level, remaining 13 samples, blood pressure was +/- 20mmHg of pre-op level.

Among 25 samples, 12 samples were conscious and arousable to call.

Remaining 13 samples were conscious and fully awake.

53

Among 25 samples, 20 samples pain score was moderate (4-6), remaining 5

samples pain score was minimal (0-3).

Among 25 samples, 9 samples temperature was 98.6F-99.5F, remaining 16

samples temperature was 95.0F- 98.6F.

The urine output among 25 samples, 15 samples, urine output was 20-30 ml/HR,

remaining 10 samples urine output was > 30 ml/HR.

The skin color among 25 samples, 4 samples had pale, dusky and yellow color

skin and remaining 21 samples had normal pink color.

The presence of protective reflex among 25 samples, 4 samples had experienced

diminished, sluggish gag reflex, remaining 21 samples had experienced the normal gag

reflex.

The activity level of between 25 samples, 1 sample was not able to move any

extremity, remaining 24 samples had normal movement of all 4 extremities.

The wound drainage color among 25 samples, 10 samples had sanguineous &

remaining 15 samples had serous color drainage.

The wound drainage amount among 25 samples, 18 samples had a moderate

amount of wound drainage & remaining 7 samples had minimal wound drainage.

Regarding surgical bleeding 24 samples experienced no surgical bleeding &

remaining 1 sample experienced moderate bleeding.

The nausea and vomiting among 25 samples, 24 samples had moderate nausea

& vomiting and treated with IV medications, the 1 sample had not experienced nausea

& vomiting.

The second objective of the study was to execute nursing interventions based on

early warning scoring system among patients following open abdominal surgeries.

Dyspnea:

1. Closely monitored respiratory rate & spo2

2. Head elevation

3. O2 administered

4. Nebulization therapy.

54

Hypertension:

1. Monitored blood pressure every 15 minutes

2. Monitored ECG continuously.

3. Closely monitored vital signs.

4. Cardiologist opinion obtained.

5. Administered antihypertensive medications as per order.

Hypotension, tachycardia, tachypnea:

1. Checked vital signs to gather baseline information

2. Applied crepe bandage to the lower extremities to promote venous return

3. IV fluids NS 500 ml was rushed intravenously over 20 mins to replace fluid

volume.

4. Inj. Vasopressin 3 ml/HR was started.

5. Auscultated chest frequently for overload.

Bradycardia:

1. Inj. Atropine 0.6 mg IV stat given which decreases vagal tone and increases

conduction through atrio ventricular node.

2. Monitored the heart rate continuously.

3. Monitored the ECG continuously.

4. Checked the heart sounds and lung sounds.

Hypothermia:

1. Monitored temperature frequently to evaluate effectiveness of intervention

2. Monitored neurological status of the patient.

3. Monitored vital signs to detect changes.

4. Provided supportive measures such as blankets, warmer

5. Administered IV fluids using fluid warmer to prevent hypovolemic

Shock.

Hyperthermia:

1. Monitored the temperature frequently.

2. Given the cold applications.

3. Inj. Paracetamol 650 mg as per order

4. Given the sponge bath. Friend.

55

Dysuria:

1. Monitored the intake output chart.

2. Encourage to drink fluids.

3. Provided privacy.

4. Attempted to stimulate the relaxation of the urethral sphincter by opening the

tape water.

Acute pain:

1. Provided comfortable position like left and right lateral as per client comfort.

2. Used non-pharmacological measures like watching T.V to reduce the perception

of pain.

3. Administered analgesics like ink. Tramadol 1 amp as per order.

4. Inspected the surgical site for swelling.

Haemorrhage:

1. Closely monitored the vital signs.

2. Provided the IV fluids as per order.

3. Observed the surgical site, tube & dressing.

Nausea and vomiting:

1. Administered Inj. Ondansetron 2 ml as per order.

2. Provided oral hygiene to promote interest in drinking.

3. Encouraged to drink fluids.

4. Administered IV fluids DNS.

Third objective was to determine the effectiveness of MEWS among patients

subjected to open abdominal surgeries.

The repeated measures ANOVA use used to determine the effectiveness of

modified early warning scoring system. The subjects were followed during the arrival

time & every 30 minutes once in the post anaesthesia care unit. The findings revealed

that there is a significant difference at p value >. 05.

By the use of MEWS, the patients received better and quicker nursing

interventions & were able to find the major symptoms as early as possible.

56

In the present study, the use of the MEWS and nursing guide helped early

detection of complications and allowed early treatment. The aim of the MEWS use is

early recognition of the patients with worsening status and to make early intervention.

It has been indicated that the MEWS allows the health care personnel to identify the

major complications earlier increase awareness of the requirements of uses of MEWS

among critically ill patients, and to facilitate the early recognition of patients with high

risk.

Conclusion:

The use of MEWS when monitoring patients during their PACU stay had

positive effects on outcomes and provided early recognition and prompt treatment of

the complications. The use of the MEWS also be continued after the patient is

transferred toward from PACU and the follow-up should be maintained in this manner

up to at least 24 hours after the operation.

Implications:

Nurses who are with the patient around the clock playing a vital role in the post-

operative care of patients with open abdominal surgery. The findings of the study have

several implications in nursing.

Nursing Practice:

1. The study gives awareness among the nurses in identifying the problems and

complications at an early stage.

2. In Post anaesthesia care unit, this study will provide insight among the nurses to

detect certain problems like

3. The developed nursing module will help in planning nursing interventions at an

early stage.

4. The present nursing module can be used by the nurses in various critical care

settings.

Nursing Education:

1. Integration of the theory and practice is a vital need and it is important in

nursing education. This study will implicate among learners to develop

observational skills and do systematic assessment which will help them detect

the problems and motivate them to render care to the patient at an early stage.

It also promotes curiosity among learners to participate with multi health team

members to provide collaborative care.

57

2. Nurses who are working in the post anaesthesia care unit are expected to have

thorough knowledge on management of patients underwent open abdominal

surgery. Early detection and identification of existing problems need quick

assessment skills among nurses to provide better care,.

3. Nursing module directs the nurse educator to teach the students to anticipate

problems of patients underwent open abdominal surgeries and execution of

priority based related nursing interventions at a moment.

Nursing Research:

1. Utilization of findings and dissemination of knowledge in nursing practice will

help to identify the complications at an early stage.

2. This study directs the nursing personnel to broaden their horizons, knowledge

and skills to elicit problems and to conduct many more research to raise their

power to implement prompt activities at the given setup.

3. The study will imply the nurse educator to conduct and motivate the learner to

select a related study with all dimensions, namely physical, mental, emotional,

social and spiritual changes encountered by the patients underwent open

abdominal surgery.

4. Utilization of findings and dissemination of knowledge which helps the nurse

educator to develop ongoing assessment, care and technology that made in the

health care system.

5. Thorough research, dissemination of knowledge will give a vision for growing

autonomy in nursing discipline.

Nursing Administration:

1. Nurse administrators can plan and organize in service education programs to the

nurses based on the study findings.

2. Nursing administrator can encourage his/her subordinate to do further research

regarding the problem of patients underwent Open abdominal surgery based on

the study result.

3. It motivates the nurse administrator to allocate resources to do further studies in

the post anaesthesia care unit.

4. Through research findings the institution can formulate policy and procedures

on care of patients underwent open abdominal surgery at the given set up by

conducting further research in this area to standardize the care

58

LIMITATIONS

Study was limited to a small setting without randomization

The result cannot be generalized to other hospital OT’s

As sample size are small, the results cannot be generalized.

RECOMMENDATIONS

A study can be replicated involving large population and sample for a longer

period. So that, the findings can be generalized.

A similar study can be done in other hospital settings.

59

CHAPTER – VI

ABSTRACT

A study entitled “a study to assess the effectiveness of early warning scoring

system and execution of nursing interventions among patients subjected to open

abdominal surgeries in the PACU at KMCH Coimbatore”

Objective: The aim of the study is to assess the trend of early warning signs of patients

following open abdominal surgeries, to determine the effectiveness of MEWS among

patients subjected to open abdominal surgeries.

Design: single group pretest posttest design.

Sample size: 25 subjects, both male and female above age of 20years following open


Conceptual framework: Ida jean Orlando’s nursing theory (1926)

Data collection procedure: After getting the verbal consent, the demographic data and

clinical characteristics were assessed in PACU by using modified early warning scoring

system.

Results: Among 25 samples, 24 samples (96%) experienced the spo2 > 90%, 1 sample

was experienced by spo2 >92% on room air. Among 25 samples, 11 samples

experienced dyspnea (or) shallow breathing, remaining 14 samples experienced that

they can deep breathe & cough well. Conclusion: The MEWS provides early

identification and treatment of patients developing complications. Thus, it is

recommended to use the MEWS and nursing interventions in post anesthetic care unit.

60

CHAPTER – VII

REFERENCES

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Score (mews) in predicting outcome of patients Undergoing abdominal surgery

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(MEWS) in -patients; A prospective observational study, journal of PMC

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emergency department patients triaged as low to moderate urgency, journal of

advanced nursing, volume 65.

62

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core.ac.uk1. modified ida jean orlando’s nursing process theory 9 2. description of age 20 3....

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